Somatoform & Dissociative Disorders

Somatoform

· Physical symptoms with no known physiological basis

· May have physical cause that is not understood

· Cannot prove null hypothesis

· Rare: lifetime prevalence < 0.05%

Somatoform & Dissociative Disorders

Dissociative

· Disruption in consciousness, memory, or identity with no known physiological basis

· May have physical cause that is not understood

· Cannot prove null hypothesis

· Lifetime prevalence unknown but estimated

0.2% (fugue) to 7.0% (amnesia)

5 Somatoform Disorders

1. Pain Disorder

2. Body Dysmorphic Disorder

3. Hypochondriasis

4. Somatization Disorder

5. Conversion Disorder

4 Dissociative Disorders

· Dissociative Amnesia

· Dissociative Fugue

· Depersonalization Disorder

· Dissociative Identity Disorder

5 Somatoform Disorders

1 -Pain Disorder

· Pain is central presenting symptom

· Psychological factors have an important role in onset, exacerbation, and maintenance of pain

· Pain interferes with social or occupational functioning

· Pain is not intentionally feigned

5 Somatoform Disorders con’d

Pain Disorder cont’d

· Difficult to diagnose:

o What pain does NOT have psychological factors?

o Pain is measured by self-report only = by definition is psychological and SUBJECTIVE

o No objective medical test for pain

o Compared to pain with known physical origins, somatoform pain may be less specific (e.g., not localized and not situational)

5 Somatoform Disorders con’d

Pain Disorder cont’d

· Prevalence unknown

· If pain is sexual, diagnosis = dyspareunia

· 10-15% of adults in US have severe enough back pain to be considered disabled, but unknown what % is somatoform

5 Somatoform Disorders con’d

2 - Body Dysmorphic Disorder

· Preoccupation with an imagined defect in appearance

· Real slight physical anomaly is exaggerated

· Preoccupation interferes with functioning

· Difficult to diagnose:

----What is a physical defect?

----How determine if anomaly is exaggerated?

5 Somatoform Disorders con’d

Body Dysmorphic Disorder cont’d

· Prevalence unknown but more common among women

· Common physical concerns: hair thinning, acne, wrinkles, scars, vascular markings, paleness, facial asymmetry, excessive facial hair, shape & size of nose, eyes, and other body parts

5 Somatoform Disorders con’d

Body Dysmorphic Disorder cont’d

· Concern can be specific (e.g. bumpy nose) or vague (e.g., ugly)

· Some spend hours each day inspecting the "defect" while others avoid looking at the "defect"

5 Somatoform Disorders con’d

3 - Hypochondriasis

· Fear of having, or the idea that one has, a serious disease based upon a misinterpretation of one or more bodily signs or symptoms when disease is not present

· Unwarranted idea of the disease persists despite medical reassurance

· Belief is not delusional (e.g. stomach ache = hole in stomach)

5 Somatoform Disorders con’d

Hypochondriasis cont’d

· Beliefs interfere with social or occupational functioning

· May or may not recognize the concern is excessive or unreasonable

· Difficult to diagnose:

o Similar to somatization dx (long hx of complaints about medical illnesses)

o A genuine medical condition may be undiagnosed

o Nontraditional healers may reinforce beliefs

5 Somatoform Disorders con’d

Hypochondriasis cont’d

· Lifetime prevalence in population 3% - 13%

· Point prevalence 5% – 9% in medical settings

· Equally common among males and females

· More common in lower socioeconomic class who complain less about psychological problems & more about physical ones

5 Somatoform Disorders con’d

Hypochondriasis cont’d

· Often "doctor shop" and have poor relationship with physician

· Commonly resist mental health referrals

· Fear of death is common and can become a phobia

· Some repeated diagnostic procedures are risky (and expensive)

5 Somatoform Disorders con’d

4 - Somatization Disorder

· History of at least 4 types of physical complaints beginning before age 30

· Complaints occur over a period of several years

· significant impairment in social or occupational functioning

5 Somatoform Disorders con’d

Somatization Disorder con’d

1 - Pain symptoms in at least 4 sites or functions

2 - At least 2 gastrointestinal symptoms other than pain

3 - At least 1 sexual or reproductive symptom other than pain

4 - At least 1 pseudo-neurological symptom

55 Somatoform Disorders con’d

Somatization Disorder cont’d

· Difficult to diagnose

· Similar to hypochondriasis but more extensive

· All symptoms could be conversion dx

· May be genuine medical problems

· Could be malingering

5 Somatoform Disorders con’d

Somatization Disorder cont’d

· Lifetime prevalence is < 1%

· More common in women than men

5 Somatoform Disorders con’d

5 -Conversion Disorder

· Formerly called "hysteria"

· One or more symptoms or deficits affecting

voluntary motor function AND/OR

sensory function

5 Somatoform Disorders con’d

Conversion Disorder cont’d

· Preceded by stress

· Not under voluntary control (i.e., not malingering)

· "la belle indiffe`rence"

· Symptoms change inexplicably

5 Somatoform Disorders con’d

Conversion Disorder cont’d

· Symptoms are not culturally sanctioned (e.g. "visions" during religious ceremony)

· Symptoms not result of a psychoactive substance

· Symptoms not limited to pain ( = pain disorder)

· Symptoms not limited to pain during sexual intercourse ( = dyspareunia)

5 Somatoform Disorders con’d

Conversion Disorder cont’d

· Difficult to diagnose:

Real medical condition may be undetected

· Lifetime prevalence < 1%

· More common among females than males

· More common in rural areas and among medically naive

Etiology of Somatoform Disorders

· Little is known, understood, or hypothesized

· Theories do not differentiate among the subtypes of somatoform dx’s

Biological/medical : stress related neurotransmitter

Psychoanalytic: conversion is a defense mechanism

Etiology of Somatoform Disorders con’d

Cognitive-behavioral:

- Situation-specific symptom expression (stressor)

- Over-attention to physical sensations

- Catastrophic interpretations of physical sensations

- Classical & operant conditioning and modeling of anxiety to physical sensations

- Attribution of poor performance to physical symptoms

- Positive & negative reinforcement of symptoms

- Deficient skills to obtain adaptive reinforcement

Treatment of Somatoform Disorders

· Psychoanalytic treatment not effective

· Cognitive behavioral has some empirical support

· Little research on most treatment approaches because:

o Somatoform dx’s are uncommon

o People experiencing somatoform dx’s usually see physicians instead of psychologists

Treatment of Somatoform Disorders con’d

Cognitive-behavioral [with humanistic elements]

· Changing cognitions about nature of physical symptoms

· Relaxation training

· PLUS

· validation/empathy/ acceptance/understanding that symptoms are real

4 Dissociative Disorders

Disruption in consciousness, memory, or identity with no known physiological basis

1. Dissociative Amnesia

2. Dissociative Fugue

3. Depersonalization Disorder

4. Dissociative Identity Disorder

4 Dissociative Disorders

1 -Dissociative Amnesia

· Inability to recall important personal information

· Memory loss is usually of a traumatic/stressful event

· Memory loss is too extensive to be explained by ordinary forgetfulness

· Symptoms cause distress or impairment

· Lack of recall not due to substance use or neurological/organic brain disorders or medical disorders or other behavioral disorders

4 Dissociative Disorders con’d

Dissociative Amnesia con’d

EXAMPLE: A 2003 newsstory about the war with Iraq:

-American soldier Jessica Lynch

-injured in battle in Iraq while in a humvee

-captured and put in Iraqi hospital

-rescued from Iraqi hospital and sent to U.S.

-much media attention

- reports no memory of the battle and rescue

-other memories and her identity remained intact

-currently adjusting to new life in hometown (e.g. college)

4 Dissociative Disorders con’d

Dissociative Amnesia con’d

· Prevalence 7.0%

· Duration of memory loss can be hours or years

· Memory loss requires adjustment

4 Dissociative Disorders con’d

Dissociative Amnesia con’d

Memory loss may be accompanied by:

· Disorientation

· Confusion

· Lack of recognition of familiar people, places, things

· Age regression

· Depressive mood

· Depersonalization

· Trance states

· Inaccurate answers to simple questions

4 Dissociative Disorders con’d

2 - Dissociative Fugue

Loss of identity:

· Memory loss far more extensive than amnesia

· Memory loss occurs after a major stressor (e.g., war battle in which a close friend was killed)

· Inability to recall one’s past

· Person suddenly develops new identity (partial or complete)

· Confusion about identity

4 Dissociative Disorders con’d

Dissociative Fugue cont’d

· Engages in sudden, unexpected travel away from home or one’s customary place of work

· Not due to other medical or psychological dx’s, or psychoactive substance use

· After return from fugue state, amnesia for traumatic events in the past before fugue

· Fugue can lead to many losses (job, partner) which may lead to depression

· Lifetime prevalence 0.2%

4 Dissociative Disorders con’d

3 -Depersonalization Disorder

Persistent or recurrent experiences of feeling

1 – being detached from oneself

2 – like an outside observer of one’s mental processes or body

--- -Reality testing remains intact

---Not a result of a substance, medical condition, or other behavioral dx (e.g., panic disorder)

4 Dissociative Disorders con’d

Depersonalization Disorder con’d

· Prevalence: 2.4%

· 50% of all adults have experienced transient feelings of depersonalization

· Precipitated by extreme stress (e.g., automobile accident; war battle; sudden death of a loved one)

4 Dissociative Disorders con’d

4 - Dissociative Identity Disorder (DID)

(Formerly "multiple personality disorder")

Very controversial whether dx exists:

· Confirmation bias and increase in rate of dx

· May be malingering

· Could be exaggeration of multiple social roles

· Difficult to measure diagnostic criteria

Dissociative Identity Disorder (DID) con’d

DIAGNOSTIC CRITERIA

· Presence of 2 or more distinct identities or personality states

(each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self)

· At least 2 of these identities or personality states recurrently take control of the person’s behavior

o Inability to recall extensive important personal information regarding alter personality

Dissociative Identity Disorder (DID) cont’d

PREVALENCE

· unknown and difficult to establish because about 2/3 rds of clinicians do not believe the dx exists

· Estimated prevalence from 0.4% (Turkey sample) to 1.3% (Canadian sample)

· More common in females than males

· Females have on avg. 15+ identities, males avg. 8

· Used to be considered very rare, e.g. 1/million

· Dx has become more popular & controversial

Etiology and Tx of Dissociative Disorders

*DID has received most attention but little research on etiology or tx for any Somatoform or Dissociative Disorders

*According to Chambless et al., 1998, no well-established treatment but some evidence that cognitive-behavioral treatment is promising

Etiology and Tx of Dissociative Disorders con’d

Etiology of Dissociative Identity Disorder (DID)

· Biological: trauma interferes with unifying cognition, emotion, and motivation

· Psychoanalytic: massive repression due to severe physical and sexual abuse during a psychosexual stage

· Cognitive- behavioral: learned avoidance of stress with exaggerated role playing

Etiology and Tx of Dissociative Disorders con’d

Treatment of Dissociative Identity Disorder (DID)

· Effectiveness of all Tx’s are unknown

· Biological: given depression and anxiety often accompany DID, use of anti-anxiety and ant-depressant medications can help those symptoms

· Psychoanalytic: hypnosis to overcome repression

· Cognitive- behavioral:

--Teach coping skills to obtain reinforcement adaptively

--Exposure to trauma that triggered the Dx

Etiology and Tx of Dissociative Disorders con’d

Treatment of Dissociative Identity Disorder (DID) con’d

Eclectic therapy

· Integrate personalities/ extinguish role playing to avoid stressful situations

· Accept alter personalities are self-generated

· Do not reinforce notion of multiple personalities

· Empathy regarding multiple personalities

· Understanding regarding childhood trauma